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ill FF RECEIVER <br /> AnalvdCal LLC SAME REC IPT CHECKLIST <br /> SRG#: l �� Date: ��(l` b <br /> Project ID: <br /> Method of Receipt: Courier Over-the-counter ipper <br /> COC Inspection ,_,,� <br /> Is COC present? Cr Y eS ❑No <br /> Custody seals on shipping container? ❑Intpct ❑Broken of present ❑N/A <br /> Is COC Signed by Relinquisher? [�es ❑No Dated? es ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes [ - <br /> NO-Is analysis or hold requested for all samples a'es ❑No <br /> Is the turnaround time indicated on COC? 2-yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No,Whiteout X10,Cross-outs <br /> Sample Inspection <br /> Coolant Present: /L [ 1'es o(i Ludes wate <br /> Temperature°C l�•`f Therm. ID# l-F Initial te/Time 071 W o �3�❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken [ 'Not present <br /> Do containers match COC? [ryes ❑No ❑No,COC lists absent sample(s) ❑No,Extra sample(s)present <br /> Are there samples matrices other than soil,water,air or carbon? ❑Yes [�'FIo <br /> Are any sample containers broken, leaking or damaged? ❑Yes Clff o <br /> Are preservatives indicated? 2'Gs, on sample containers 2'1 es, on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Dl'es ❑No ❑N/A <br /> Are samples within holding time for analyses requested? [?Yes ❑No <br /> Are the correct sample containers used for the analyses requested? z T'es ❑No <br /> Is there sufficient sample to perform testing? gTes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes Ea<o <br /> Receipt ils �o <br /> Matrix Container type � #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: to Time: v 0-- <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample conta' er(s) �n Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? es E]No ❑N/A <br /> Is the Project ID indicated: ❑On COC [JOn sample container(s) On Both El Not indicated <br /> If project ID is listed on both COC and containers,do they all match? Vies ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? Yes No El N/A <br /> Are the sample collection times indicated: E]On COC E]On sample con ainer(s) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers, do they all match? 19yes No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 13 of 17 Page 12 of 16 <br />